Effectiveness of decentralising outpatient wasting treatment

Wasting is the most acute form of undernutrition, and increases the risk of mortality, especially in the most severe cases and when combined with infectious diseases. Standard outpatient treatment of uncomplicated wasting is usually centralised in health centres and separated into different programmes according to case severity. The treatment landscape is complex, involving different  locations and different nutritional products managed by different agencies. Severe wasting is typically treated by nurses in health centres with ready-to-use therapeutic food (RUTF). Moderate wasting, which lacked standardised international guidelines until recently, is managed by health workers or community health workers (CHWs) with other nutritional products. This disjointed approach complicates detection, treatment, and supply chain management, leading to suboptimal treatment coverage.

To address these challenges, new simplified approaches have been proposed, including the decentralisation of treatment to CHWs through integrated community case management (iCCM). This approach has shown promise in improving treatment coverage and effectiveness at lower costs, though some studies indicate that CHWs may struggle with the current protocols, particularly for severe cases, due to low literacy levels and inadequate supervision.

The article by Lopez-Ejeda et al. focuses on a study conducted in Mali, a country facing a complex humanitarian crisis, particularly in the northern Gao region. The study aimed to assess the effectiveness of decentralising wasting treatment using CHWs and incorporating both severe and moderate cases within the same programme using a simplified protocol. This three-armed cluster randomised controlled trial included a control group who received standard treatment by nurses in health centres. The first intervention group applied the same standard treatment protocol but added CHWs as providers (iCCM standard group). The second intervention arm also added CHWs and applied a combined simplified protocol. This protocol used mid-upper arm circumference (MUAC) as the sole anthropometric criterion for diagnosis and discharge, coupled with a fixed dose of RUTF to treat both severe (2 sachets) and moderate cases (1 sachet) (iCCM simplified group).

The study found that recovery rates were 76% in the control group, 82% in the iCCM standard group, and 93% in the iCCM simplified group. Among severe cases, use of therapeutic food was significantly lower in the simplified combined programme than the control (43 sachets fewer) with similar anthropometric gains. With the simplified protocol, the CHWs recorded 6% errors, compared with 19% with the standard protocol. Programme coverage increased with the simplified combined programme (+42.5% for severe cases and +13.8% for moderate cases).

The study suggests that decentralising treatment from health facilities and using a simplified protocol can improve access to care, maintain effective treatment outcomes, and reduce costs, making it a viable approach in emergency settings. This approach could be particularly beneficial in resource-limited and conflict-affected environments, where access to centralised healthcare is challenging. However, challenges such as early discharge, particularly in severe cases, and the need for improved health worker training and supervision were highlighted.